Great Barr Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that patients were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Requires Improvement. At this assessment, the rating has changed to Good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Patients felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service. Managers encouraged staff to raise concerns when things went wrong. The provider had processes for staff to report incidents, near misses and safety events. The practice had a significant events policy which was accessible to all staff members. Staff felt there was an open culture, and that safety was a top priority.

The service consistently demonstrated openness and candour when things went wrong. Patients received timely and meaningful apologies alongside appropriate support. Significant Event Analysis (SEA) processes were comprehensive and well embedded. Over the previous 12 months, 15 SEAs had been completed and reviewed, demonstrating a clear approach to recording events, reflective practice and continuous improvement. We saw clear evidence of thorough investigation and detailed reporting of incidents. Staff we spoke with were aware of the reporting process and how incidents and events were discussed regularly to disseminate learning across the team and mitigate future risks.

There was a system to record and investigate complaints and when things went wrong, staff apologised and gave patients support. Information reviewed demonstrated that patients had opportunities to provide feedback, and they knew how to make a complaint. Lessons were learned from individual complaints and shared with the practice team to improve the quality of care. Feedback and information were available in the practice and on their website.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services.

Effective systems were in place for processing information relating to new patients including the summarising of new records. The service worked with other providers to deliver shared care and when patients moved between services. Systems ensured that all patient information, including laboratory results and referrals, were reviewed and actioned promptly. Referrals to specialist and urgent services, including two-week wait (2WW) pathways, were managed through well-defined and consistently applied processes.

The practice operated a robust and responsive on call system, with a designated GP available on duty each day to provide immediate clinical support and advice for queries. This enabled timely decision making, enhanced patient safety, and supported effective prioritisation of care.

The provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment.

There were a range of structured meetings in place. These included multi-disciplinary, governance, clinical and practice team meetings.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

At the last assessment in 2025 we identified that processes in place were not regularly updated and we identified gaps in the information held on patients with potential safeguarding concerns. At this assessment, we found the practice had reviewed and strengthened its safeguarding processes. Safeguarding registers had been rebuilt to support a systematic approach to identifying, recording and monitoring concerns, ensuring patients were appropriately coded and safeguarding information was kept up to date

Safeguarding leadership and accountability were clearly defined. There was a named GP lead for safeguarding and appointed safeguarding leads. All staff contributed to safeguarding oversight and weekly meetings were in place. Governance was further strengthened through clear documentation and auditability.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable patients and acted on concerns working in partnership with other organisations.

There were systems in place for the renewal of DBS checks. DBS checks identify whether a person has a criminal record or is on an official list of patients barred from working in roles where they may have contact with children or adults who may be vulnerable.

The service worked with patients to understand and manage risks by thinking holistically. They provided care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

All staff were trained in basic life support and staff could recognise a deteriorating patient. They knew of the action to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying any concerns. Patients were advised about risks related to their condition and the actions to take if their symptoms deteriorated. Staff were aware of the location of emergency medicines and equipment, which was appropriately maintained.

Leaders told us that they worked with services locally to understand and manage risks. The practice also had registers in place to support those patients who were vulnerable or who had mobility or communication needs.

Staff demonstrated a strong understanding of emergency protocols and had received appropriate training in basic life support and sepsis.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Health and safety related assessments and procedures to manage health and safety were in place. A range of health and safety risk assessments and fire risk assessments had been completed. Regular monitoring was in place to ensure guidelines were adhered to and all staff had been made aware of the appropriate procedures to follow.

Staff had been provided with training in health and safety related topics such as fire safety, infection control, basic life support and resuscitation training. Staff reported they had no concerns regarding the arrangements in place to ensure health and safety.

Policies and procedures were in place to support the effective management of health and safety. The practice carried out regular environmental audits, with any identified actions addressed promptly. Learning from these audits was shared through well-established internal systems, fostering a strong culture of continuous learning and improvement.

All electrical equipment had been appropriately calibrated, and safety tested in line with regulations. Safety alerts relating to equipment were effectively disseminated to relevant staff and acted upon in a timely manner, ensuring risks were minimised.

Fire safety policies were in place and staff were aware of how to access these. Fire marshals had undertaken additional training for the role. Systems were in place for the regular checks of fire alarms, extinguishers and fire evacuation procedures with regular checks carried out around the building.

There was a business continuity plan in place which was monitored and reviewed. Reception and administration staff who handled calls to the practice and arranged appointments with the clinical team were aware of potential red flag symptoms. Staff knew when to notify a GP or other clinicians with concerns about a patient who may be acutely unwell and/or deteriorating.

Arrangements for accessing emergency equipment were well embedded. Effective systems were in place for the checking and monitoring of emergency equipment and medicines. The practice held all recommended items, including oxygen and an automated external defibrillator (AED). An exceptionally well organised emergency bag was in place, to respond promptly and safely in high pressure situations.

During our site visit we found the premises were well maintained. The practice demonstrated an embedded and proactive safety culture, with effective systems that enabled risks to be consistently identified, managed and learned from. These arrangements ensured the environment, equipment and facilities were well organised to support the delivery of safe and high-quality care.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

Since the last assessment in 2025, the clinical leadership team had reviewed their processes for supervision of staff and had implemented effective systems for all staff carrying out clinical roles. A structured programme of clinical supervision and regular audits was in place to provide oversight, support and assurance that staff were working within the agreed scope of their roles and maintaining high standards of practice. This included regular, clearly documented supervision records and attendance at the weekly clinical meetings to ensure clinical updates were shared across the team. We found training was up to date, learning needs and development of staff was managed appropriately and staff were working within their agreed areas of competence. Staff training was comprehensive and up to date, with clear systems in place to identify and support learning and development needs.

An effective on call system was in place, with a designated GP available each day. This enabled clinical oversight, including reviewing urgent requests, supporting reception staff, managing demand when same day capacity was exceeded and making decisions regarding home visits. This approach strengthened risk management and supported timely, safe decision-making.

The practice had recruitment policies in place, and all staff had completed disclosure and barring checks. A role specific induction process was in place for all new staff. Leaders ensured staff competency following induction through structured assessment to confirm they were suitably prepared to carry out their roles safely and effectively. Staff described the induction process as comprehensive and supportive.

The leadership team had undertaken a full review of staff roles and responsibilities to identify key operational areas and drive improvement by developing staff. There was a strong culture of progression, with staff supported to take on additional responsibilities, including lead roles. Opportunities for further training were actively encouraged and aligned to both individual aspirations and service requirements. Annual appraisals focused on performance, development and wellbeing, and were aligned with the organisation’s vision and values.

There were a range of clinical and non-clinical roles within the practice. The practice also benefited from a multidisciplinary team through its Primary Care Network (PCN), including pharmacists, a social prescriber and paramedic. Systems were in place to ensure these staff were safely recruited, appropriately trained, and working within their scope of practice.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

An infection control audit had been completed to identify potential risks and take appropriate action where required. At the time of the onsite assessment, the audit provided to us had been completed in March 2026, and the practice had achieved 96% overall. The action plan had identified wipeable furniture was required in some of the clinical rooms. We found this had been acted on and 6 new chairs had been purchased.

The practice had a designated Infection, Prevention and Control (IPC) lead and all staff had completed training relevant to their role. Staff were aware of the systems and processes to follow to ensure clinical specimens were handled safely.

The environment was visibly clean, well maintained and appropriately equipped to support safe care. Clinical rooms were suitably stocked with essential equipment, including personal protective equipment (PPE), pedal bins and hand hygiene facilities. Cleaning arrangements were effective, with contracted cleaning staff in place and cleaning schedules consistently followed.

The practice had policies in place for infection, prevention and control which were accessible to staff and staff were aware of the action to take. For example, in the event of a sharps or contamination injury.

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happened.

Since the last assessment in 2025, the practice had made significant improvements in the management of medicines. We carried out a random selection of clinical searches to review how patients’ medicines were monitored and if the appropriate care and treatment was being received. For example, we carried out a search to identify the number of patients with a potential missed diagnosis of diabetes. The review of HbA1c (HbA1c is a blood test that shows the average level of blood glucose) results demonstrated that all patient results had been appropriately reviewed and acted upon in line with clinical guidance. Where results indicated pre-diabetes or diabetes, the appropriate clinical action, advice, or follow-up was undertaken and documented. The practice’s systems for reviewing HbA1c results supported timely identification, management, and ongoing monitoring of patients, ensuring safe and effective care.

As part of the assessment, we reviewed the number of patients who had been prescribed ACE inhibitors and angiotensin II receptor blockers (ARBs) medicines used to control blood pressure. The search identified a potential of 1 patient potentially overdue for monitoring. We reviewed the record and found the patient had been followed up in July 2026 to have their monitoring completed. Evidence of patient contact was clearly documented in the clinical records.

We found the practice’s approach to medication reviews supported safe and effective prescribing, with clearly defined pathways to ensure the appropriate reviews were in place. We carried out a search to identify patients who had received a medication review in the past 3 months. The search identified 159 patients. We reviewed a random sample of 5 records and found thorough medicine reviews had been completed by the GPs and clinical pharmacists with clear documentation and evidence of safety, and ongoing monitoring where required.

The practice worked with the clinical pharmacists from the local Primary Care Network (PCN) to monitor patients and the prescribing of medicines. All safety alerts were sent to the clinical pharmacists and leadership team to disseminate the information. The provider was able to demonstrate they had processes in place in relation to safety alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA).

There was a programme of regular clinical audits of prescribing that focused on improving care and treatment. The practice pharmacy team had also developed a suite of tools to assist in the monitoring of medicines. Evidence provided showed a total of 22 audits and quality improvement projects had been completed between August 2025 and May 2026. Each audit followed NICE and national guidelines.

Emergency medicines, vaccines and medical equipment had clear monitoring processes in place. There were appropriate arrangements in place for the management of vaccines and for maintaining the cold chain. We saw fridge temperatures were routinely monitored and vaccines reviewed at random were in date and stored appropriately.

Patients knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Staff managed prescription stationery appropriately and securely. Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the number of antimicrobials issued by the provider was in line with the local and national averages.